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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603579
Report Date: 11/08/2022
Date Signed: 11/08/2022 11:42:16 AM

Document Has Been Signed on 11/08/2022 11:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DELTA HOME CAREFACILITY NUMBER:
198603579
ADMINISTRATOR:MAXIMO, ROSAMARIAFACILITY TYPE:
740
ADDRESS:2433 ANGELA STREETTELEPHONE:
(626) 912-3415
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
11/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Rosamaria Maximo, LicenseeTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Galarza made an announced visit and met with Licensee/Administrator Rosamaria Maximo to conduct a pre-Licensing evaluation. The facility presently has four (4) non-ambulatory developmentally disabled adults. It is serviced by San Gabriel/Pomona Regional Center as a level 4C home. The facility has a Dementia plan and hospice waiver for four (4) residents.

An application was submitted to Community Care Licensing Department (CCLD) for a change of ownership of an RCFE (Residential Care For the Elderly) for developmentally disabled adults. The requested capacity is for four (4) non-ambulatory residents; of which one (1) may be bedridden. Structure: Facility is a single-story home consisting of four (4) bedrooms, two (2) full bathrooms, kitchen, dining room, living room, laundry room, medication room/storage, office, and a 2-car detached garage. The front yard has grass. The backyard has shaded patio furniture. Auditory alarms are operable in all exit doors. Bedroom Clients: All bedrooms are private. Bedrooms # 2-4 have exit doors leading to the side yard. Bedroom #1 is designated as bedridden. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lightning. Bathrooms: Have a working toilet, wash basin, and bathtub. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in bedroom closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. One (1) fully charged fire extinguisher is in place. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Smoke Detectors: There are smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer were observed. The stove's two back burners are not working. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff.

See LIC 809C for continuation of report.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DELTA HOME CARE
FACILITY NUMBER: 198603579
VISIT DATE: 11/08/2022
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Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications are stored in the kitchen. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: Designated area for files will be in the office room. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 9/14/2022 for four (4) [3 non-ambulatory & 1 bedridden] residents. The facility has no delayed egress. The facility has a fire pull alarm. Component III: Component III PowerPoint presentation was waived.

The following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA Galarza by December 6, 2022. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. The stove two back burner do not work. Repair and/or replace. Submit picture proof and an invoice if applicable.

An exit interview was conducted, and a copy of this report has been furnished to Licensee/Administrator Rosamaria Maximo. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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